Linköping University Medical Dissertation No.831 Passive Smoking in Children The Importance of Parents’ Smoking and Use of Protective Measures AnnaKarin Johansson Division of Paediatrics, Department of Molecular and Clinical Medicine Linköping 2004 © Copyright AnnaKarin Johansson 2004 Cover art Anders Blomqvist Published articles have been reprinted with permission of the respective copyright holder: Elsevier, PTID socety, Oxford University Press. Printed in Sweden by Akademitryck AB, Edsbruk 2003-11-24 ISBN 91-7373-801-8 ISSN 0345-0082 To Göran, Stefan, Ulf and Daniel My aim was to contribute to the future and not to blame the past Linköping University Medical Dissertation No. 831 Passive Smoking in Children The Importance of Parents’ Smoking and Use of Protective Measures AnnaKarin Johansson Abstract Passive smoking has been recognised as a health hazard, and children are especially vulnerable. The general aim of this thesis was to describe and analyse the importance of parents’ smoking and smoking behaviour for children’s tobacco smoke exposure. The studies were conducted in the South-East part of Sweden and pre-school children and their parents constituted the study samples. Five studies are described in six papers. Smoking prevalence among parents (14%) and commonly used measures of protection were surveyed. An instrument designed to measure children’s tobacco smoke exposure in the home was developed and validated. It was used on 687 families with a smoking parent and a child 2½-3 years old, included in a prospective cohort study on environmental variables of importance for immun-mediated diseases ABIS (All Babies in South-East Sweden). Almost 60% of the parents stated that they always smoked outdoors with the door closed, 14% mixed this with smoking near the kitchen fan, 12% near an open door, 7% mixed all these behaviours and 8 % smoked indoors without precautions. The smoking behaviours were related to the children’s creatinine adjusted urine cotinine. All groups had significantly higher values than had children from non-smoking homes, controls. Outdoor smoking with the door closed seemed to be the best, though not a total, measure for tobacco smoke protection in the home. Most parents were aware of the importance of protecting children from tobacco smoke exposure but all were not convinced of the increased risk for disease for exposed children. The majority of parents were not satisfied with the smoking prevention in health-care and 50% did not think that their smoking was of any concern to the child health care nurse. Further research is warranted to describe if the difference in exposure score related to smoking behaviours is related to different prevalence of disease. Efforts are needed to convince those who still smoke indoors that tobacco smoke exposure influence children’s health and that consequent outdoor smoking with the door closed seemed to give the best protection. Key words: ETS, infant, child, cotinine, smoking behaviour, protective measures, parents, home, tobacco, child health care, ABIS Division of Paediatrics Department of Molecular and Clinical Medicine Faculty of Health Sciences, Linköping University, SE 58185 Linköping, Sweden ISBN 91-7373-801-8 ISSN 0345-0082 ABBREVATIONS ABIS All Babies in South-East Sweden BC Before Christ CCR Cotinine/Creatinine Ratio CHC Child Health Clinic CHD Cardiovascular Heart Disease CI Confidence Interval CO Carbon monoxide ETS Environmental Tobacco Smoke EU European Union LLQ Lowest Level of Quantification OR Odds Ratio RSP Respirable Suspended Particles WHO World Health Organisation Definitions: Dependent children individuals 0-19 years old Immigrants individuals not born in Sweden Indoor smoker a smoker, smoking sometimes or always anywhere indoors, including standing near an open door or window or near the kitchen fan (I,II,VI) Indoor smoker a smoker, smoking anywhere indoors, at dinner table or near the TVset (III–V). Outdoor smoker a smoker always smoking outdoors with the door closed Passive smoking the inhaling of ETS; diluted sidestream smoke and exhaled mainstream smoke Pre-school children individuals 0-6 years old School children individuals 7-19 years old Smoker daily and occasional smokers Smoking behaviour active choice of places when smoking LIST OF ORIGINAL PAPERS This thesis is based on the following papers, which will be referred to in the text by their roman numerals. I Indoor and outdoor smoking: Impact on children’s health. Johansson AK, Hermansson G, Halling A. European Journal of Public Health 2003; 13: 61–6, copyright (2003), with permission from Oxford University press II Does having children affect adult smoking and behaviours at home? Johansson AK, Halling A, LinQuest study group Tobacco Induced Diseases 2003; 1: 175–83, copyright (2003), with permission from PTID society III Assessment of smoking behaviours in the home and their influence on children’s passive smoking: development of a questionnaire. Johansson AK, Halling A, Hermansson G, Ludvigsson J. Submitted to Annals of Epidemiology IV When does exposure of children to tobacco smoke become child abuse? Johansson AK, Hermansson G, Ludvigsson J. The Lancet 2003; 361: 1828 [letter], copyright (2003), with permission from Elsevier V How should parents protect their children from ETS exposure in the home? Johansson AK, Hermansson G, Ludvigsson J. Accepted for publication in Pediatrics. VI Attitudes to children’s tobacco smoke exposure among smoking and non-smoking parents and their opinions on how the issue is handled in health care. Johansson AK, Hermansson G, Ludvigsson J. Revised and resubmitted to J Pediatric Health Care CONTENTS INTRODUCTION................................................................................................................................................................... 1 BACKGROUND...................................................................................................................................................................... 3 THE HISTORY OF SMOKING........................................................................................................................................3 SMOKING CAUSES ADVERSE HEALTH EFFECTS..............................................................................................6 PASSIVE SMOKING...........................................................................................................................................................7 PASSIVE SMOKING CAUSES ADVERSE HEALTH EFFECTS...........................................................................8 THE CHILD’S INCREASED SENSITIVITY TO ETS EXPOSURE.......................................................................9 ADVERSE HEALTH EFFECTS FROM CHILDREN’S ETS EXPOSURE..........................................................9 METHODOLOGICAL CONSIDERATIONS IN RESEARCH ON SMOKING AND TOBACCO SMOKE EXPOSURE .........................................................................................................................................................................11 Questionnaires................................................................................................................................................................12 Objective assessment methods:....................................................................................................................................12 THE ABIS STUDY.............................................................................................................................................................15 TOBACCO SMOKE EXPOSURE AND CHILD ABUSE .........................................................................................18 THE PROTECTION MOTIVATION THEORY..........................................................................................................19 INCITEMENTS FOR THE STUDIES ............................................................................................................................22 AIMS .........................................................................................................................................................................................24 SUBJECTS..............................................................................................................................................................................25 STUDY 1 .................................................................................................................................................................................25 STUDY II................................................................................................................................................................................25 STUDY III ..............................................................................................................................................................................25 STUDY IV...............................................................................................................................................................................26 STUDY V.................................................................................................................................................................................26 STUDY VI...............................................................................................................................................................................26 METHODS .............................................................................................................................................................................29